<!DOCTYPE html>
<html lang="en">
    <head>
        <meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
        <title>聚银支付</title>
        <meta name="viewport" content="width=device-width, initial-scale=1.0">
    </head>
    
    <body>
        <form method="post" action="{:url('api/juyin.juyinpaytest/requestdaifu')}">
            <table width="50%" border="0" align="center" cellpadding="0" cellspacing="0" style="border:solid 1px #107929">
                <tr>
                    <td colspan="2" bgcolor="#CEE7BD">代付申请接口</td>
                </tr>
                <tr>
                    <td align="left">&nbsp;&nbsp;商户号</td>
                    <td align="left">&nbsp;&nbsp;<input size="50" type="text" name="memberid" id="memberid"  value="10382"/>
    &nbsp;<span style="color:#FF0000;font-weight:100;">*</span></td>
                </tr>
                
                <tr>
                    <td align="left">&nbsp;&nbsp;出款帐号</td>
                    <td align="left">&nbsp;&nbsp;<input size="50" type="text" name="account" id="account"  value="4001173390"/>
    &nbsp;<span style="color:#FF0000;font-weight:100;">*</span></td>
                </tr>

                <tr>
                    <td align="left">&nbsp;&nbsp;银行代码</td>
                    <td align="left">&nbsp;&nbsp;<input size="50" type="text" name="bankName" id="bankName"  value="ICBC"/>
    &nbsp; </td>
                </tr>
                
                <tr>
                    <td align="left">&nbsp;&nbsp;银行卡帐号(支付宝帐号)</td>
                    <td align="left">&nbsp;&nbsp;<input size="50" type="text" name="bankCard" id="bankCard"  value="6212262010022989443"/>
    &nbsp; </td>
                </tr>
                
                <tr>
                    <td align="left">&nbsp;&nbsp;开户人(支付宝名称)</td>
                    <td align="left">&nbsp;&nbsp;<input size="50" type="text" name="ownerName" id="ownerName" value="陈科燕" />		  		
                            &nbsp;<span style="color:#FF0000;font-weight:100;">*</span></td>
                </tr>
                
                <tr>
                    <td align="left">&nbsp;&nbsp;省份代码</td>
                    <td align="left">&nbsp;&nbsp;<input size="50" type="text" name="provinceCode" id="provinceCode" value="1" />		  		
                            &nbsp;<span style="color:#FF0000;font-weight:100;">*</span></td>
                </tr>
                
                <tr>
                    <td align="left">&nbsp;&nbsp;城市代码</td>
                    <td align="left">&nbsp;&nbsp;<input size="50" type="text" name="cityCode" id="cityCode"  value="1"/> 
                                    &nbsp;<span style="color:#FF0000;font-weight:100;">*</span></td>
                </tr>
                
                <tr>
                    <td align="left">&nbsp;&nbsp;金额</td>
                    <td align="left">&nbsp;&nbsp;<input size="50" type="text" name="amount" id="amount"  value="19700"/>
    &nbsp; </td>
                </tr>
                               
                <tr>
                    <td align="left">&nbsp;&nbsp;商户订单号</td>
                    <td align="left">&nbsp;&nbsp;<input size="50" type="text" name="mem_order" id="memOrder"  value="<?php echo $memOrder ?>"/>
    &nbsp; </td>
                </tr>

                <tr>
                    <td align="left">&nbsp;</td>
                    <td align="left">&nbsp;&nbsp;<input type="submit" value="提交" /></td>
                </tr>

                <tr>
                  <td height="5" bgcolor="#6BBE18" colspan="2"></td>
                </tr>
            </table>
        </form>
    </body>
</html>
